Efficacy and safety of Ciprofol compared with Propofol during general anesthesia induction: A systematic review and meta-analysis of randomized controlled trials (RCT)

BACKGROUND

Ciprofol, a newer entrant with similarities to propofol, has shown promise with a potentially improved safety profile, making it an attractive alternative for induction of general anesthesia. This meta-analysis aimed to assess the safety and efficacy of ciprofol compared with propofol during general anesthesia induction.

METHODS

A comprehensive literature search was conducted using PubMed, Clinical Trial.gov, and Cochrane Library databases from inception to July 2023 to identify relevant studies. All statistical analyses were conducted using R statistical software version 4.1.2.

RESULTS

Thirteen Randomized Controlled Trials (RCTs) encompassing a total of 1998 participants, were included in our analysis. The pooled analysis indicated that Ciprofol was associated with a notably lower incidence of pain upon injection [RR: 0.15; 95% CI: 0.10 to 0.23; I^2 = 43%, p < 0.0000001] and was non-inferior to propofol in terms of anesthesia success rate [RR: 1.00; 95% CI: 0.99 to 1.01; I^2 = 0%; p = 0.43]. In terms of safety, the incidence of hypotension was significantly lower in the ciprofol group [RR:0.82; 95% CI:0.68 to 0.98; I^2 = 48%; p = 0.03]. However, no statistically significant differences were found for postoperative hypertension, bradycardia, or tachycardia.

CONCLUSION

In conclusion, Ciprofol is not inferior to Propofol in terms of its effectiveness in general anesthesia. Ciprofol emerges as a valuable alternative sedative with fewer side effects, especially reduced injection pain, when compared to Propofol.

SUMMARY

Propofol, frequently utilized as an anesthetic, provides swift onset and quick recovery. However, it has drawbacks such as a narrow effective dosage range and a high occurrence of adverse effects, particularly pain upon injection. Ciprofol, a more recent drug with propofol-like properties, has demonstrated promise and may have an improved safety profile, making it a compelling alternative for inducing general anesthesia. This meta-analysis compared the safety and effectiveness of Ciprofol with Propofol for general anesthesia induction in a range of medical procedures, encompassing thirteen Randomized Controlled Trials (RCTs) and 1998 individuals. The pooled analysis indicated that Ciprofol was associated with a notably lower incidence of pain upon injection [RR: 0.15; 95% CI: 0.10 to 0.23; I^2 = 43%, p < 0.0000001] and was non-inferior to propofol in terms of anesthesia success rate [RR: 1.00; 95% CI: 0.99 to 1.01; I^2 = 0%; p = 0.43]. In terms of safety, the incidence of hypotension was significantly lower in the ciprofol group [RR:0.82; 95% CI:0.68 to 0.98; I^2 = 48%; p = 0.03]. However, no statistically significant differences were found for hypertension, bradycardia, or tachycardia. In conclusion, ciprofol is equally effective at inducing and maintaining general anesthesia as propofol. When compared to propofol, ciprofol is a better alternative sedative for operations including fiberoptic bronchoscopy, gynecological procedures, gastrointestinal endoscopic procedures, and elective surgeries because it has less adverse effects, most notably less painful injections.

Social network analysis for medical narcotics in South Korea: focusing on patients and healthcare organizations

BACKGROUND

Medical narcotics must be administered under medical supervision because of their potential for misuse and abuse, leading to more dangerous and addictive substances. The control of medical narcotics requires close monitoring to ensure that they remain safe and effective. This study proposes a methodology that can effectively identify the overprescription of medical narcotics in hospitals and patients.

METHODS

Social network analysis (SNA) was applied to prescription networks for medical narcotics. Prescription data were obtained from the Narcotics Information Management System in South Korea, which contains all data on narcotic usage nationwide. Two-mode networks comprising hospitals and patients were constructed based on prescription data from 2019 to 2021 for the three most significant narcotics: appetite suppressants, zolpidem, and propofol. Two-mode networks were then converted into one-mode networks for hospitals. Network structures and characteristics were analyzed to identify hospitals suspected of overprescribing.

RESULTS

The SNA identified hospitals that overprescribed medical narcotics. Patients suspected of experiencing narcotic addiction seek treatment in such hospitals. The structure of the network was different for the three narcotics. While appetite suppressants and propofol networks had a more centralized structure, zolpidem networks showed a less centralized but more fragmented structure. During the analysis, two types of hospitals caught our attention: one with a high degree, meaning that potential abusers have frequently visited the hospital, and the other with a high weighted degree, meaning that the hospital may overprescribe. For appetite suppressants, these two types of hospitals matched 84.6%, compared with 30.0% for propofol. In all three narcotics, clinics accounted for the largest share of the network. Patients using appetite suppressants were most likely to visit multiple locations, whereas those using zolpidem and propofol tended to form communities around their neighborhoods.

CONCLUSIONS

The significance of this study lies in its analysis of nationwide narcotic use reports and the differences observed across different types of narcotics. The social network structure between hospitals and patients varies depending on the composition of the medical narcotics. Therefore, these characteristics should be considered when controlling medication with narcotics. The results of this study provide guidelines for controlling narcotic use in other countries.

Construction of preclinical evidence for propofol in the treatment of reperfusion injury after acute myocardial infarction: A systematic review and meta-analysis

Propofol, a commonly used intravenous anesthetic, has demonstrated potential in protecting against myocardial ischemia/reperfusion injury (MIRI) based on preclinical animal studies. However, the clinical benefits of propofol in this context are subject to debate. We conducted a systematic search across eight databases to identify all relevant animal studies investigating the preventive effects of propofol on MIRI until October 30, 2023. We assessed the methodological quality of the included studies using SYRCLE's bias risk tool. Statistical analysis was performed using STATA 15.1. The primary outcome measures analyzed in this study were myocardial infarct size (IS) and myocardial injury biomarkers. This study presents a comprehensive analysis of 48 relevant animal studies investigating propofol's preventive effects on MIRI. Propofol administration demonstrated a reduction in myocardial IS and decreased levels of myocardial injury biomarkers (CK-MB, LDH, cTnI). Moreover, propofol improved myocardial function parameters (+dp/dtmax, -dP/dtmax, LVEF, LVFS), exhibited favorable effects on inflammatory markers (IL-6, TNF-α) and oxidative stress markers (SOD, MDA), and reduced myocardial cell apoptotic index (AI). These findings suggest propofol exerts cardioprotective effects by reducing myocardial injury, decreasing infarct size, and improving heart function. However, the absence of animal models that accurately represent comorbidities such as aging and hypertension, as well as inconsistent administration methods that align with clinical practice, may hinder its clinical translation. Further robust investigations are required to validate these findings, elucidate the underlying mechanisms of propofol, and facilitate its potential translation into clinical practice.

Adverse Drug Events Observed with the Newly Approved Remimazolam in Comparison to Propofol for General Anesthesia in Patients Undergoing Surgery: A Meta-analysis

INTRODUCTION

Developments in anesthetic pharmacology have been aiming at minimizing physiological disturbance in addition to maintaining and improving titrateability, recovery profile, and patient experience. Remimazolam, a GABAAlpha receptor agonist, is a new intravenous anesthetic agent which has recently been approved for use. This analysis aimed to systematically compare the adverse drug events reported with the newly approved remimazolam in comparison to propofol for general anesthesia (GA) in patients undergoing surgery.

METHODS

Electronic databases were searched from 15 May to 20 December 2023 for relevant publications which compared the outcomes reported with the newly approved remimazolam versus propofol in patients undergoing surgery. Relevant reported adverse drug events were the endpoints of this study. The statistical analysis was carried out using the latest version of the RevMan software. Data analysis was represented by risk ratio (RR) with 95% confidence intervals (CI).

RESULTS

Sixteen studies with a total number of 1897 participants were included in this analysis; 1104 participants received remimazolam and 793 participants received propofol. The risks for hypotension (RR 0.50, 95% CI 0.43-0.58; P = 0.00001), hypoxemia (RR 0.43, 95% CI 0.19-0.99; P = 0.05), bradycardia (RR 0.53, 95% CI 0.36-0.78; P = 0.001), pain at injection site (RR 0.07, 95% CI 0.01-0.56; P = 0.01), and total adverse events (RR 0.33, 95% CI 0.24-0.47; P = 0.00001) were significantly lower with remimazolam. However, no significant differences were observed in terms of postoperative nausea and vomiting (RR 0.98, 95% CI 0.66-1.46; P = 0.93), dizziness (RR 0.42, 95% CI 0.11-1.57; P = 0.20), psychiatric symptoms (RR 1.09, 95% CI 0.45-2.67; P = 0.85), and respiratory depression (RR 0.81, 95% CI 0.24-2.76; P = 0.74).

CONCLUSION

Our current analysis showed that the newly approved remimazolam was apparently associated with significantly fewer adverse drug events in comparison to propofol for GA in patients undergoing surgery. Therefore, this new drug should be further studied and more research with larger population sizes should be carried out to confirm this hypothesis.

Clinical efficacy of adjunctive esketamine anesthesia in electroconvulsive therapy for major depressive disorders: A pragmatic, randomized, controlled trial

Electroconvulsive therapy (ECT) is an effective treatment for depression, and esketamine has been shown to have antidepressant effects. However, it is currently unclear whether adjunctive esketamine can enhance the clinical efficacy of ECT in real-world clinical practice. In this pragmatic clinical trial, patients with major depression were randomly assigned into two groups: patients received 0.25 mg/kg esketamine plus propofol (esketamine group) or the same volume of saline (control group) plus propofol. Results indicated that there was no difference in response and remission rates between the two groups. However, patients receiving esketamine had a higher remission rate of SI and lower psychotic scores. Patients receiving esketamine also required a lower electric dose, but the seizure duration and cognitive function were comparable between the two groups. Diastolic blood pressure increased after esketamine injection, but there was no increased risk of hypertension. Furthermore, incidence of delirium and confusion were comparable between the groups. Conclusively, adjunctive esketamine anesthesia does not provide any advantage in improving the response and remission rates of ECT. However, it can improve remission of SI and alleviate accompanying psychotic symptoms in depressive patients. With adjunctive usage, the adverse cardiovascular and neuropsychiatric events associated with esketamine appear to be tolerable.

Efficacy of propofol-supplemented cardioplegia on biomarkers of organ injury in patients having cardiac surgery using cardiopulmonary bypass: A protocol for a randomised controlled study (ProMPT2)

INTRODUCTION

Cardiac surgery with cardiopulmonary bypass and cardioplegic arrest is known to be responsible for ischaemia and reperfusion organ injury. In a previous study, ProMPT, in patients undergoing coronary artery bypass or aortic valve surgery we demonstrated improved cardiac protection when supplementing the cardioplegia solution with propofol (6 mcg/ml). The aim of the ProMPT2 study is to determine whether higher levels of propofol added to the cardioplegia could result in increased cardiac protection.

METHODS AND ANALYSIS

The ProMPT2 study is a multi-centre, parallel, three-group, randomised controlled trial in adults undergoing non-emergency isolated coronary artery bypass graft surgery with cardiopulmonary bypass. A total of 240 patients will be randomised in a 1:1:1 ratio to receive either cardioplegia supplementation with high dose of propofol (12 mcg/ml), low dose of propofol (6 mcg/ml) or placebo (saline). The primary outcome is myocardial injury, assessed by serial measurements of myocardial troponin T up to 48 hours after surgery. Secondary outcomes include biomarkers of renal function (creatinine) and metabolism (lactate).

ETHICS AND DISSEMINATION

The trial received research ethics approval from South Central - Berkshire B Research Ethics Committee and Medicines and Healthcare products Regulatory Agency in September 2018. Any findings will be shared though peer-reviewed publications and presented at international and national meetings. Participants will be informed of results through patient organisations and newsletters.

TRIAL REGISTRATION

ISRCTN15255199. Registered in March 2019.

Restrictive use of Restraints and Delirium Duration in the Intensive Care Unit (R2D2-ICU): protocol for a French multicentre parallel-group open-label randomised controlled trial

INTRODUCTION

Physical restraint (PR) is prescribed in patients receiving invasive mechanical ventilation in the intensive care unit (ICU) to avoid unplanned removal of medical devices. However, it is associated with an increased risk of delirium. We hypothesise that a restrictive use of PR, as compared with a systematic use, could reduce the duration of delirium in ICU patients receiving invasive mechanical ventilation.

METHODS AND ANALYSIS

The Restrictive use of Restraints and Delirium Duration in ICU (R2D2-ICU) study is a national multicentric, parallel-group, randomised (1:1) open-label, controlled, superiority trial, which will be conducted in 10 ICUs. A total of 422 adult patients requiring invasive mechanical ventilation for an expected duration of at least 48 hours and eligible for prescription of PR will be randomly allocated within 6 hours from intubation to either the restrictive PR use group or the systematic PR use group, until day 14, ICU discharge or death, whichever comes first. In both groups, PR will consist of the use of wrist straps. The primary endpoint will be delirium or coma-free days, defined as the number of days spent alive in the ICU without coma or delirium within the first 14 days after randomisation. Delirium will be assessed using the Confusion Assessment Method-ICU twice daily. Key secondary endpoints will encompass agitation episodes, opioid, propofol, benzodiazepine and antipsychotic drug exposure during the 14-day intervention period, along with a core outcome set of measures evaluated 90 days postrandomisation.

ETHICS AND DISSEMINATION

The R2D2-ICU study has been approved by the Comité de Protection des Personnes (CPP) ILE DE FRANCE III-PARIS (CPP19.09.06.37521) on June 10th, 2019). Participant recruitment started on 25 January 2021. Results will be published in international peer-reviewed medical journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT04273360.

Application of propofol-remifentanil intravenous general anesthesia combined with regional block in pediatric ophthalmic surgery

OBJECTIVE

The aim of this study is to observe the anesthetic effect and safety of intravenous anesthesia without muscle relaxant with propofol-remifentanil combined with regional block under laryngeal mask airway in pediatric ophthalmologic surgery.

METHODS

A total of 90 undergoing ophthalmic surgery were anesthetized with general anesthesia using the laryngeal mask airway without muscle relaxant. They were randomly divided into two groups: 45 children who received propofol-remifentanil intravenous anesthesia combined with regional block (LG group), and 45 children who received total intravenous anesthesia (G group). The peri-operative circulatory indicators, awakening time after general anesthesia, postoperative analgesic effect and the incidence of anesthesia-related adverse events were respectively compared between the two groups.

RESULTS

All the children successfully underwent the surgical procedure. The awakening time after general anesthesia and removal time of laryngeal mask were significantly shorter in the LG group than in the G group (P < 0.05). There was no statistically significant difference in the heart rates in the perioperative period between the two groups (P > 0.05). There was no statistically significant difference in the incidence of intraoperative physical response, respiratory depression, postoperative nausea and vomiting (PONV) and emergence agitation (EA) between the two groups (P > 0.05). The pain score at the postoperative hour 2 was lower in the LG group than in the G group (P < 0.05).

CONCLUSION

Propofol-remifentanil intravenous anesthesia combined with long-acting local anesthetic regional block anesthesia, combined with laryngeal mask ventilation technology without muscle relaxants, can be safely used in pediatric eye surgery to achieve rapid and smooth recovery from general anesthesia and better postoperative analgesia. This anesthesia scheme can improve the comfort and safety of children in perioperative period, and has a certain clinical popularization value.

Volatile versus propofol sedation after cardiac valve surgery: a single-center prospective randomized controlled trial

BACKGROUND

Optimal intensive care of patients undergoing valve surgery is a complex balancing act between sedation for monitoring and timely postoperative awakening. It remains unclear, if these requirements can be fulfilled by volatile sedations in intensive care medicine in an efficient manner. Therefore, this study aimed to assess the time to extubation and secondary the workload required.

METHODS

We conducted a prospective randomized single-center trial at a tertiary university hospital to evaluate the postoperative management of open valve surgery patients. The study was randomized with regard to the use of volatile sedation compared to propofol sedation. Sedation was discontinued 60 min after admission for critical postoperative monitoring.

RESULTS

We observed a significantly earlier extubation (91 ± 39 min vs. 167 ± 77 min; p < 0.001), eye-opening (86 ± 28 min vs. 151 ± 71 min; p < 0.001) and command compliance (93 ± 38 min vs. 164 ± 75 min; p < 0.001) using volatile sedation, which in turn was associated with a significantly increased workload of a median of 9:56 min (± 4:16 min) set-up time. We did not observe any differences in complications. Cardiopulmonary bypass time did not differ between the groups 101 (IQR 81; 113) versus 112 (IQR 79; 136) minutes p = 0.36.

CONCLUSIONS

Using volatile sedation is associated with few minutes additional workload in assembling and enables a significantly accelerated evaluation of vulnerable patient groups. Volatile sedation has considerable advantages and emerges as a safe sedation technique in our vulnerable study population.

TRIAL REGISTRATION

Clinical trials registration (NCT04958668) was completed on 1 July 2021.

Association of Early Dexmedetomidine Utilization With Clinical and Functional Outcomes Following Moderate-Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study

OBJECTIVE

To examine early sedation patterns, as well as the association of dexmedetomidine exposure, with clinical and functional outcomes among mechanically ventilated patients with moderate-severe traumatic brain injury (msTBI).

DESIGN

Retrospective cohort study with prospectively collected data.

SETTING

Eighteen Level-1 Trauma Centers, United States.

PATIENTS

Adult (age > 17) patients with msTBI (as defined by Glasgow Coma Scale < 13) who required mechanical ventilation from the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Using propensity-weighted models, we examined the association of early dexmedetomidine exposure (within the first 5 d of ICU admission) with the primary outcome of 6-month Glasgow Outcomes Scale Extended (GOS-E) and the following secondary outcomes: length of hospital stay, hospital mortality, 6-month Disability Rating Scale (DRS), and 6-month mortality. The study population included 352 subjects who required mechanical ventilation within 24 hours of admission. The initial sedative medication was propofol for 240 patients (68%), midazolam for 59 patients (17%), ketamine for 6 patients (2%), dexmedetomidine for 3 patients (1%), and 43 patients (12%) never received continuous sedation. Early dexmedetomidine was administered in 77 of the patients (22%), usually as a second-line agent. Compared with unexposed patients, early dexmedetomidine exposure was not associated with better 6-month GOS-E (weighted odds ratio [OR] = 1.48; 95% CI, 0.98-2.25). Early dexmedetomidine exposure was associated with lower DRS (weighted OR = -3.04; 95% CI, -5.88 to -0.21). In patients requiring ICP monitoring within the first 24 hours of admission, early dexmedetomidine exposure was associated with higher 6-month GOS-E score (OR 2.17; 95% CI, 1.24-3.80), lower DRS score (adjusted mean difference, -5.81; 95% CI, -9.38 to 2.25), and reduced length of hospital stay (hazard ratio = 1.50; 95% CI, 1.02-2.20).

CONCLUSION

Variation exists in early sedation choice among mechanically ventilated patients with msTBI. Early dexmedetomidine exposure was not associated with improved 6-month functional outcomes in the entire population, although may have clinical benefit in patients with indications for ICP monitoring.

Propofol improves survival in a murine model of sepsis via inhibiting Rab5a-mediated intracellular trafficking of TLR4

BACKGROUND

Propofol is a widely used anesthetic and sedative, which has been reported to exert an anti-inflammatory effect. TLR4 plays a critical role in coordinating the immuno-inflammatory response during sepsis. Whether propofol can act as an immunomodulator through regulating TLR4 is still unclear. Given its potential as a sepsis therapy, we investigated the mechanisms underlying the immunomodulatory activity of propofol.

METHODS

The effects of propofol on TLR4 and Rab5a (a master regulator involved in intracellular trafficking of immune factors) were investigated in macrophage (from Rab5a-/- and WT mice) following treatment with lipopolysaccharide (LPS) or cecal ligation and puncture (CLP) in vitro and in vivo, and peripheral blood monocyte from sepsis patients and healthy volunteers.

RESULTS

We showed that propofol reduced membrane TLR4 expression on macrophages in vitro and in vivo. Rab5a participated in TLR4 intracellular trafficking and both Rab5a expression and the interaction between Rab5a and TLR4 were inhibited by propofol. We also showed Rab5a upregulation in peripheral blood monocytes of septic patients, accompanied by increased TLR4 expression on the cell surface. Propofol downregulated the expression of Rab5a and TLR4 in these cells.

CONCLUSIONS

We demonstrated that Rab5a regulates intracellular trafficking of TLR4 and that propofol reduces membrane TLR4 expression on macrophages by targeting Rab5a. Our study not only reveals a novel mechanism for the immunomodulatory effect of propofol but also indicates that Rab5a may be a potential therapeutic target against sepsis.

The efficacy and safety of using a combination of rocuronium and sugammadex for awake craniotomy anesthesia: A randomized clinical trial

BACKGROUND

Awake craniotomy (AC) is a neurosurgical method for the resection of brain lesions located in eloquent areas to achieve maximal and safe resection. A patient's arousal quality is essential for the success of the operation. This study compared the arousal time and quality after AC achieved by 2 different drug combinations: rocuronium with sugammadex and propofol with remifentanil.

METHODS

This prospective, randomized, controlled trial included 42 adult patients undergoing AC with a laryngeal mask, who were randomly assigned to either a rocuronium-sugammadex group (RS; n = 21) or a propofol-remifentanil without muscle relaxant group (nRS; n = 21). The primary outcomes were the arousal time and arousal quality. The secondary outcomes included the number of laryngeal mask airway (LMA) adjustments and diaphragmatic excursion length.

RESULTS

This study included 42 participants. The median (IQR) arousal time was 13.5 minutes (7-20) in the RS group and 21 minutes (16.5-26.5) in the nRS group (P = .005). There was no significant difference in arousal quality between the 2 groups (P = .229). LMA adjustments were significantly less frequent in the nRS group than in the RS group [0.25 times (±0.62) vs 1.26 times (±1.17), P = .001]. Adverse events, such as spontaneous movements and brain swelling, were more frequent in the nRS group than in the RS group.

CONCLUSIONS

Using a combination of rocuronium and sugammadex with propofol and remifentanil may shorten the awakening time, reduce the duration of laryngeal mask adjustment, and do not affect the arousal quality and postoperative outcomes for patients undergoing awake craniotomy, compared to propofol and remifentanil alone.

Efficacy and safety of ciprofol versus propofol for anesthesia induction in adult patients received elective surgeries: a meta‑analysis

BACKGROUND

Propofol is use widely used in anesthesia, known for its effectiveness, may lead to cardiopulmonary issues in some patients. Ciprofol has emerged as a possible alternative to propofol because it can achieve comparable effects to propofol while causing fewer adverse events at lower doses. However, no definitive conclusion has been reached yet. This meta-analysis aimed to evaluate the efficacy and safety of ciprofol versus propofol in adult patients undergoing elective surgeries under general anesthesia.

METHODS

We searched PubMed, EMBASE, the Cochrane library, Web of Science, and Chinese National Knowledge Infrastructure (CNKI) to identify potentially eligible randomized controlled trials (RCT) comparing ciprofol with propofol in general anesthesia until September 30, 2023. The efficacy outcomes encompassed induction success rate, time to onset of successful induction, time to disappearance of eyelash reflex, and overall estimate means in Bispectral Index (BIS). Safety outcomes were assessed through time to full alertness, incidence of hypotension, incidence of arrhythmia, and incidence of injection-site pain. Continuous variables were expressed as mean difference (MD) with 95% confidence interval (CI), and dichotomous variables were expressed as risk ratio (RR) with 95% CI. Statistical analyses were performed using RevMan 5.4 and STATA 14.0. The quality of the evidence was rated through the grading of recommendations, assessment, development and evaluation (GRADE) system.

RESULTS

A total of 712 patients from 6 RCTs were analyzed. Meta-analysis suggested that ciprofol was equivalent to propofol in terms of successful induction rate, time to onset of successful induction, time to disappearance of eyelash reflex, time to full alertness, and incidence of arrhythmia, while ciprofol was better than propofol in overall estimated mean in BIS (MD: -3.79, 95% CI: -4.57 to -3.01, p < 0.001), incidence of hypotension (RR: 0.63, 95% CI: 0.42 to 0.94, p = 0.02), and incidence of injection-site pain (RR: 0.26, 95% CI: 0.14 to 0.47, p < 0.001). All results were supported by moderate to high evidence.

CONCLUSIONS

Ciprofol may be a promising alternative to propofol because it facilitates achieving a satisfactory anesthesia depth and results in fewer hypotension and injection-site pain. However, we still recommend conducting more studies with large-scale studies to validate our findings because only limited data were accumulated in this study.

TRIAL REGISTRATION

PROSPERO 2023 CRD42023479767.

Efficacy of remimazolam tosilate versus propofol for total intravenous anaesthesia in urological surgery: A randomised clinical trial

BACKGROUND

Remimazolam is a novel ultra-short-acting benzodiazepine sedative that acts on the gamma-aminobutyric acid type A receptor (GABAAR).

OBJECTIVE

To compare the efficacies of remimazolam (RMZ), and propofol (PROP) combined with remifentanil and cisatracurium for total intravenous anaesthesia (TIVA) in patients undergoing urological surgery.

DESIGN

A prospective, single-blind, randomised, noninferiority clinical trial.

SETTING

Single centre from 1 January 2022 to 30 March 2022.

PATIENTS

A total of 146 adult patients undergoing elective urological surgery.

INTERVENTION

Patients were randomly allocated in a 1 : 1 ratio to the PROP or RMZ groups. In the PROP group, anaesthesia was induced with propofol at 100 mg min -1 to reach a bispectral index score (BIS) of 40 to 60. After loss of consciousness (LOC), intravenous fentanyl 3 μg kg -1 was administered, followed by cisatracurium 0.3 mg kg -1 . Patients were intubated 3 min after cisatracurium administration. Anaesthesia was maintained with the combination of propofol (plasma concentration: 2.5 to 4 μg ml -1 ) and remifentanil (plasma concentration: 2.5 to 4 ng ml -1 ). In the RMZ group, anaesthesia was induced with remimazolam tosilate starting at 10 mg kg -1  h -1 to reach a BIS of 40 to 60 and maintained between 0.2 and 2 mg kg -1  h -1 . After LOC, fentanyl and cisatracurium were administered and intubation was performed as in the PROP group. Anaesthesia was maintained with a combination of remimazolam (0.2 to 2 mg kg -1  h -1 ) and remifentanil (plasma concentration: 2.5 to 4 ng ml -1 ).

MAIN OUTCOME MEASURES

The primary outcome was the TIVA success rate. The predefined noninferiority margin considered an absolute difference of 6% in the primary outcome between the groups. The secondary outcomes were vital signs, anaesthesia and surgery characteristics, and adverse events.

RESULTS

All patients completed the trial. The success rates of TIVA with remimazolam and propofol were 100 and 98.6%, respectively. The incidence of hypotension during anaesthesia was lower in the RMZ group (26%) than in the PROP group (46.6%) ( P  = 0.016). The median [IQR] total consumption of ephedrine during anaesthesia was higher in the PROP group 10 [0 to 12.5] mg than in the RMZ group 0 [0 to 10] mg ( P  = 0.0002). The incidence of injection pain was significantly higher in the PROP group (76.7%) than in the RMZ group (0; P  < 0.001). No significant differences in the controllability of the anaesthesia depth, anaesthesia and surgery characteristics, or vital signs were observed between the groups.

CONCLUSION

Remimazolam demonstrated noninferior efficacy to propofol combined with remifentanil and cisatracurium for TIVA in patients undergoing urological surgery.

TRIAL REGISTRATION

Chictr.org.cn, identifier: ChiCTR2100050923.

CLINICAL REGISTRATION

The study was registered in the Chinese Clinical Trial Registry (ChiCTR2100050923, Principal investigator: Xuehai Guan, Date of registration: 8 November 2021, https://www.chictr.org.cn/showproj.html?proj=133466 ).

Inhaled anesthesia associated with reduced mortality in patients with stage III breast cancer: A population-based study

BACKGROUND

Patients diagnosed with stage III breast cancer often undergo surgery, radiation therapy, and chemotherapy as part of their treatment. The choice of anesthesia technique during surgery has been a subject of interest due to its potential association with immune changes and prognosis. In this study, we aimed to compare the mortality rates between stage III breast cancer patients undergoing surgery with propofol-based intravenous general anesthesia and those receiving inhaled anesthetics.

METHODS

Using data from Taiwan's National Health Insurance Research Database and Taiwan Cancer Registry, we identified a cohort of 10,896 stage III breast cancer patients. Among them, 1,506 received propofol-based intravenous anesthetic maintenance, while 9,390 received inhaled anesthetic maintenance. To ensure comparability between the two groups, we performed propensity-score matching.

RESULTS

Our findings revealed a significantly lower mortality rate in patients who received inhaled anesthetics compared to those who received propofol-based intravenous anesthesia. Sensitivity analysis further confirmed the robustness of our results.

CONCLUSIONS

This study suggests that inhaled anesthesia technique is associated with a lower mortality rate in clinical stage III breast cancer. Further research is needed to validate and expand upon these results.

Opioid-free anesthesia with ultrasound-guided quadratus lumborum block in the supine position for lower abdominal or pelvic surgery: a randomized controlled trial

In the past, quadratus lumborum block (QLB) was mostly used for postoperative analgesia in patients, and few anesthesiologists applied it during surgery with opioid-free anesthesia (OFA). Consequently, it is still unclear whether QLB in the supine position can provide perfect analgesia and inhibit anesthetic stress during surgery under the OFA strategy. To observe the clinical efficacy of ultrasound-guided quadratus lumborum block (US-QLB) in the supine position with OFA for lower abdominal and pelvic surgery. A total of 122 patients who underwent lower abdominal or pelvic surgery in People's Hospital of Wanning between March 2021 and July 2022 were selected and divided into a quadratus lumborum block group (Q) (n = 62) and control group (C) (n = 60) according to the random number table method. Both groups underwent general anesthesia combined with QLB in the supine position. After sedation, unilateral or bilateral QLB was performed via the ultrasound guided anterior approach based on images resembling a "human eye" and "baby in a cradle" under local anesthesia according to the needs of the operative field. In group Q, 20 ml of 0.50% lidocaine and 0.20% ropivacaine diluted in normal saline (NS) were injected into each side. In group C, 20 ml of NS was injected into each side. The values of BP, HR, SPO2, SE, RE, SPI, NRS, Steward score, dosage of propofol, dexmedetomidine, and rocuronium, the number of patients who needed remifentanil, propofol, or diltiazem, puncture point, block plane, duration of anesthesia, catheter extraction, and wakefulness during the operation were monitored. There were no significant differences in the general data, number of cases requiring additional remifentanil, propofol, or diltiazem treatment, as well as puncture point and puncture plane between the two groups (P > 0.05). HR, SBP, and DBP values were higher in group Q than in group C at T1; HR, SPI, and SE, while RE values were lower in group Q than in group C at T3, SE, and RE; the Steward score was higher in group Q than in group C at T4 and T5, and the difference was statistically significant (P < 0.05). The extubation and awake times were lower in group Q than in group C, and the difference was statistically significant (P < 0.05). The SE, RE, and SPI values were lower at T1, T2, T3, and T4 than at T0. The Steward scores at T4 and T5 were higher in group Q than in group C, and were lower than at T0, with a statistically significant difference (P < 0.05). There were significant differences in the effectiveness of postoperative analgesia between the two groups at t1, t3 and t4 (P < 0.05). US-QLB in the supine position with OFA is effective in patients undergoing lower abdominal or pelvic surgery with stable intraoperative vital signs, complete recovery and better postoperative analgesia.

Deep continuous sedation at the patient's request until death in a palliative care unit: retrospective study

OBJECTIVES

Limited descriptive data are available on continuous and deep sedation maintained until death (CDSUD) at the patient's request in palliative care units. This study aimed to describe such practices in the context of refractory suffering or after a request to stop life-sustaining treatment, evaluating the duration and dosage of sedative treatments used.

METHODS

This retrospective observational study included consecutively hospitalised patients in a palliative care unit from January 2020 to December 2021. Data on patient profiles, reasons for the sedation request, duration of sedation and doses of sedatives were collected.

RESULTS

Among 42 patients who underwent CDSUD, 79% occurred due to refractory suffering. In cases of sedation following a request to stop life support, high-dose corticosteroid therapy was the most commonly involved life-sustaining treatment. Midazolam was always the first-line sedative treatment. Chlorpromazine was added in 79% of cases, and propofol in 40%, to achieve a deep level of sedation. The mean maximum doses of midazolam, chlorpromazine and propofol were 7.6 mg/hour (±1.9), 3.3 mg/hour (±0.9) and 1.7 mg/kg/hour, respectively. The average duration of sedation was 37 hours.

CONCLUSIONS

This study provides new descriptive elements on CDSUD. Notably, it highlights the use of second-line sedative molecules, such as propofol.

Medium- and long-chain triglyceride propofol activates PI3K/AKT pathway and inhibits non-alcoholic fatty liver disease by inhibiting lipid accumulation

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease. The mechanism by which medium- and long-chain triglyceride (MCT/LCT) propofol plays a role in promoting NAFLD remains unclear. In this study, we investigated the effect of MCT/LCT propofol on NAFLD progression and its mechanism of action. In Huh-7 and HepG3 cells induced by free fatty acids (FFA), propofol downregulated the expression levels of TG and lipid metabolism-related proteins by promoting the activation of the PI3K/AKT pathway and suppressing FFA-induced lipid metabolic disorders. In a high-fat diet (HFD) -induced NAFLD mouse model, we demonstrated that propofol significantly inhibited liver steatosis, inflammatory cell infiltration, and fibrosis. In conclusion, our results suggest that MCT/LCT propofol reduces liver lipid accumulation by activating the PI3K/AKT pathway and further suppressing the NAFLD process.

The association between intraoperative anesthesia methods used during gastric cancer surgery and long-term mortality: A retrospective observational study using a Japanese claims database

PURPOSE

Various basic and clinical studies have investigated the association between the types of anesthetic agents and prognosis. However, the results have varied among studies and remain controversial. In the present study, we aimed to investigate whether the risk of all-cause mortality differs between inhaled or intravenous anesthetics in patients with gastric cancer undergoing gastrectomy.

METHODS

Using a Japanese nationwide insurance claims database, we analyzed patients who underwent gastrectomy under general anesthesia for gastric cancer between January 2005 and September 2019. Postoperative outcomes were compared between two groups: those who received inhaled anesthetics (Sevoflurane, Isoflurane, or Desflurane) and those who received intravenous anesthetics (propofol), using a multivariable Cox proportional hazards model. The primary outcome was overall survival.

RESULTS

Among 2671 eligible patients, 2105 were in the inhaled anesthetic group, and 566 were in the intravenous anesthetic group. The median (interquartile range) age was 58 (51-63) years, and 1979 (74.1%) were men. The median follow-up period was 795 days. We identified 56 (2.7%) and 16 (2.8%) deaths during the follow-up period in the inhaled and intravenous anesthetic use groups, respectively. There was no difference in postoperative overall survival between the two groups (hazard ratio, 0.97; 95% confidence interval, 0.56-1.70; P = 0.93).

CONCLUSIONS

We found no significant difference in the postoperative risks of overall survival between inhaled and intravenous anesthesia in patients with gastric cancer undergoing gastrectomy.

Re: Propofol in Triple Trouble Kearns-Sayre Syndrome, Dyggve-Melchior-Clausen Syndrome, and Chromosome-9 Inversion

NONE

Sub-dose anesthetics combined with chloride regulators protect the brain against chronic ischemia-hypoxia injury

BACKGROUND

Cerebral ischemia-hypoxia leads to excitotoxicity-mediated neuronal damage and cognitive dysfunction, especially in the elderly. Excessive intracellular [Cl- ]i accumulation weakens γ-aminobutyric acid (GABA) compensatory effects. Sub-anesthetic dose of propofol protected the brain against ischemia-hypoxia, which was abolished by blocking Cl- efflux transporter K+ /Cl- cotransporter 2 (KCC2). We aimed to determine whether low-dose anesthetic combined with [Cl- ]i regulators could restore the compensatory GABAergic system and improve cognitive function.

METHODS

Chronic cerebral hypoxia (CCH) model was established by bilateral carotid artery ligation in aged rats. Sub-dose of anesthetics (propofol and sevoflurane) with or without KCC2 agonist N-ethylmaleimide (NEM) or Na+ /K+ /Cl- cotransporter 1 (NKCC1) antagonist bumetanide (BTN) was administered systemically 30 days post-surgery. Primary rat hippocampal neuronal cultures were subjected to hypoxic injury with or without drug treatment. Memory function, hippocampal neuronal survival, GABAergic system functioning, and brain-derived neurotrophic factor (BDNF) expressions were evaluated.

RESULTS

Sub-anesthetic dose of combined propofol (1.2 μg mL-1 ) and sevoflurane [0.7 MAC (minimum alveolar concentration)] did not aggravate the hypoxic brain injury in rats or cell damage in neuronal cultures. Adding either BTN or NEM protected against hypoxic injury, associated with improved cognitive function in vivo, less intracellular accumulation of [Cl- ]i , reduced cell death, restored GABAergic compensation, and increased BDNF expression both in vivo and in vitro.

CONCLUSION

Sub-anesthetic dose of propofol and sevoflurane is a recommended anesthesia regimen in at-risk patients. Restoration of [Cl- ]i homeostasis and GABAergic could further reduce the brain damage caused by ischemia-hypoxia.

Alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B Trial): protocol for a multicentre phase 3 pragmatic clinical and cost-effectiveness randomised trial in the UK

INTRODUCTION

Almost all patients receiving mechanical ventilation (MV) in intensive care units (ICUs) require analgesia and sedation. The most widely used sedative drug is propofol, but there is uncertainty whether alpha2-agonists are superior. The alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B) trial aims to determine whether clonidine or dexmedetomidine (or both) are clinically and cost-effective in MV ICU patients compared with usual care.

METHODS AND ANALYSIS

Adult ICU patients within 48 hours of starting MV, expected to require at least 24 hours further MV, are randomised in an open-label three arm trial to receive propofol (usual care) or clonidine or dexmedetomidine as primary sedative, plus analgesia according to local practice. Exclusions include patients with primary brain injury; postcardiac arrest; other neurological conditions; or bradycardia. Unless clinically contraindicated, sedation is titrated using weight-based dosing guidance to achieve a Richmond-Agitation-Sedation score of -2 or greater as early as considered safe by clinicians. The primary outcome is time to successful extubation. Secondary ICU outcomes include delirium and coma incidence/duration, sedation quality, predefined adverse events, mortality and ICU length of stay. Post-ICU outcomes include mortality, anxiety and depression, post-traumatic stress, cognitive function and health-related quality of life at 6-month follow-up. A process evaluation and health economic evaluation are embedded in the trial.The analytic framework uses a hierarchical approach to maximise efficiency and control type I error. Stage 1 tests whether each alpha2-agonist is superior to propofol. If either/both interventions are superior, stages 2 and 3 testing explores which alpha2-agonist is more effective. To detect a mean difference of 2 days in MV duration, we aim to recruit 1437 patients (479 per group) in 40-50 UK ICUs.

ETHICS AND DISSEMINATION

The Scotland A REC approved the trial (18/SS/0085). We use a surrogate decision-maker or deferred consent model consistent with UK law. Dissemination will be via publications, presentations and updated guidelines.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT03653832.

Remimazolam besylate versus propofol for deep sedation in critically ill patients: a randomized pilot study

OBJECTIVE

To compare the efficacy and safety of remimazolam besylate and propofol for deep sedation in critically ill patients.

METHODS

In this single-center, prospective, randomized, controlled pilot study, patients in the intensive care unit (ICU) requiring deep sedation were randomized to receive remimazolam besylate or propofol intravenously. Deep sedation was defined as a Richmond Agitation and Sedation Scale (RASS) score of - 4 or - 5. Sedation depth was monitored using RASS and Narcotrend Index (NI). The primary outcome was the percentage of time within the target sedation range without rescue sedation. The secondary outcomes included ventilator-free hours within 7 days, successful extubation, length of ICU stay, and 28-day mortality. Adverse events during the interventional period were also recorded.

RESULTS

Thirty patients were assigned to each group. The median (IQR) RASS score was - 5.0 (- 5.0, - 4.0), and the median (IQR) NI value was 29.0 (21.0, 37.0) during the intervention period. Target RASS was reached a median of 100% of the sedation time in the two groups. No significant differences were observed in ventilator-free hours within 7 days, successful extubation, length of ICU stay, or 28-day mortality among groups. Hypotension occurred in 16 (53.3%) patients of remimazolam group and 18 (60.0%) patients of propofol group (p > 0.05). No patient experienced bradycardia.

CONCLUSIONS

Remimazolam besylate appears to be an effective and safe agent for short-term deep sedation in critically ill patients. Our findings warrant large sample-sized randomized clinical trials.

Erector spinae plane block versus local infiltration anaesthesia for transforaminal percutaneous endoscopic discectomy: A prospective randomised controlled trial

BACKGROUND

Around 60%-80% of the population suffers from back pain, making it one of the most common health complaints. Transforaminal percutaneous endoscopic discectomy (TPED) is an effective treatment for low back pain that can be performed using different anaesthesia techniques. Our primary objective was to test the hypothesis that bilateral Erector spinae plane block (ESP) plus sedation is equally effective as traditional local infiltration anaesthesia plus sedation in TPED.

MATERIALS AND METHODS

Fifty-two patients undergoing TPED were randomly assigned to 2 groups: G1 - intravenous sedation with local infiltration anaesthesia; G2 - intravenous sedation with bilateral ESP.

PRIMARY OUTCOME

volume of fentanyl and propofol administered during surgery.

SECONDARY OUTCOMES

adverse events during sedation reported using the World Society of Intravenous Anaesthesia (SIVA) adverse sedation event tool, level of postoperative sedation measured on the Richmond Agitation-Sedation Scale (RASS), intensity of postoperative pain on a visual analogue scale (VAS), mechanical pain threshold (MPT) measured with von Frey monofilaments on both lower extremities, patient satisfaction with analgesia on 5-point Likert scale.

RESULTS

Volume of fentanyl, propofol, and level of postoperative sedation was significantly lower in G2 (p < 0.001). There was no difference between groups in intensity of pain, patient satisfaction with analgesia, and mechanical pain threshold after surgery. There were no adverse events in G2, but in G1 2 patients presented minimal risk descriptors, 5 presented minor risk descriptors, and 1 presented sentinel risk descriptors that required additional medication or rescue ventilation.

CONCLUSIONS

The ESP was equal to local infiltration anaesthesia in terms of intensity of pain, mechanical pain threshold after surgery, and patient satisfaction; however, ESP reduced the volume of intraoperative fentanyl and propofol, thereby reducing the adverse effects of sedation.

Propofol and Kearns-Sayre Syndrome: An idiographic approach

With the focus on an idiographic approach whereby the observations incorporated the various dimensions of individual functioning 'top-down' to 'bottom-up', this case report describes the successful management of a 14-year-old girl with Kearns-Sayre syndrome and Dyggve-Melchior-Clausen disease requiring a transvenous permanent pacemaker implantation for complete heart block. The patient presented to a tertiary care centre in Muscat, Oman, in 2023 seeking consultation. The current idiographic approach appears to have a heuristic value for 2 interrelated reasons. Firstly, it is unlikely that even tertiary care units can accrue such rare presentations and scrutinise them under nomothetic approach. Secondly, by employing the idiographic approach that is capable of examining each case in-depth, the aspiration for good health and well-being may come to the forefront. To the best of the authors' knowledge this is the first published idiographic report in anaesthesia care.

The risks of sedation and pain control during burn resuscitation: Increased opioids lead to over-resuscitation and hypotension

INTRODUCTION

Pain management and sedation are necessary in severely burned persons. Balancing pain control, obtundation, and hemodynamic suppression can be challenging. We hypothesized that increased sedation during burn resuscitation is associated with increased intravenous fluid administration and hemodynamic instability.

METHODS

A retrospective review of a single burn center was performed from 2014 to 2019 for all admissions to the burn unit with > 20% total body surface area (TBSA) burns. Within 48 h of admission, we compared total amounts of sedation/pain medications (morphine milligram equivalents (MME), propofol, dexmedetomidine, benzodiazepines) with total resuscitation volumes and frequency of hypotensive episodes. Resuscitation volumes and frequency of hypotension were modeled with multivariable linear regression adjusting for burn severity and weight.

RESULTS

208 patients were included with median age of 43 years (IQR 29-55) and median %TBSA of 31 (IQR 25-44). Median 48-hour resuscitation milliliters per weight per %TBSA were 3.3 (IQR 2.28-4.92). Pain/sedative medications included a combination of opioids in 99%, benzodiazepines in 73%, propofol in 31%, and dexmedetomidine in 11% of patients. MMEs were associated with greater resuscitation volumes (95% CI: 0.15-0.54, p = 0.01) as well as number of hypotensive events (95% CI: 1.57-2.7, p < 0.001). No associations were noted with other sedative medications when comparing the number of hypotensive events and resuscitation volumes.

CONCLUSIONS

Increased opioid administration has physiological consequences and should be carefully monitored during resuscitation as higher volume administrations lead to worse outcomes. Opioids and sedating medications should be titrated to the least amount needed to achieve reasonable comfort and sedation.

Anesthetic Effect of Dezocine Combined with Propofol in Laparoscopic Surgery and Its Influence on T Cells and Inflammatory Factors in Patients

Objective

To investigate the anesthetic effects of combining dezocine with propofol during laparoscopic surgeries, particularly its impact on T cells and inflammation.

Methods

A prospective study was conducted on 80 patients undergoing laparoscopy at the Third Hospital of Qiqihar Medical University from January 1, 2021, to August 1, 2022. Patients were randomly divided into two groups of 40 each using the random number table method. The combined group received 0.1mg/kg dezocine and 2.5 mg/kg propofol, while the control group received only 2.5 mg/kg propofol. Postoperative levels of NK cells, T cells, TNF-α, and IL-1β were analyzed.

Results

Postoperative recovery times, including spontaneous breathing, eye-opening, verbal response, extubation, and orientation, were notably shorter in the combined group compared to the control. While both groups showed an increase in TNF-α and IL-1β levels post-surgery, the combined group had significantly lower levels at specific timepoints (T1, T2). This group also showed elevated levels of NK cells, CD4+, and CD4+/CD8+. Additionally, the combined group reported significantly less pain and had fewer patients with a low body condition score after extubation. No significant difference was observed in postoperative adverse reactions between the groups.

Conclusions

Combining dezocine with propofol offers superior anesthesia for laparoscopic procedures. This combination not only enhances recovery speed and reduces postoperative pain but also maintains high safety standards.

Initial loading of dexmedetomidine and continuous propofol sedation for prevention of delayed recovery: A randomized controlled trial

BACKGROUND

Sedation with continuous dexmedetomidine and bolus midazolam administration provides a lower incidence of unacceptable patient movement during procedures but requires a longer recovery time. The authors aimed to compare recovery time and unacceptable patient movement during sedation with initial loading of dexmedetomidine followed by continuous propofol infusion with those during sedation with continuous dexmedetomidine and bolus midazolam administration.

METHODS

In this prospective randomized controlled trial, 54 patients undergoing dental surgery and requiring intravenous sedation were assigned to either the dexmedetomidine and propofol group (n = 27, dexmedetomidine administered at 6 μg/kg/h for 5 minutes, followed by continuous propofol infusion using a target-controlled infusion) or the dexmedetomidine and midazolam group (n = 27, dexmedetomidine administered at 0.2-0.7 μg/kg/h continuously after the same initial loading dose with bolus midazolam). A bispectral index of 70 through 80 was maintained during the procedure. Patient movement that interfered with the procedure and time from the end of sedation to achieving a negative Romberg sign were assessed.

RESULTS

Times from the end of sedation to achieving a negative Romberg sign in the dexmedetomidine and propofol group (median, 14 minutes [interquartile range, 12-15 minutes]) were significantly shorter (P < .001) than in the dexmedetomidine and midazolam group (median, 22 minutes [interquartile range, 17.5-30.5 minutes]). The incidence of unacceptable patient movement was comparable between groups (n = 3 in the dexmedetomidine and propofol group, n = 4 in the dexmedetomidine and midazolam group; P = .999).

CONCLUSIONS

Sedation with a single loading dose of dexmedetomidine followed by continuous propofol infusion can prevent delayed recovery without increasing unacceptable patient movement.

PRACTICAL IMPLICATIONS

The combination of dexmedetomidine and propofol may provide high-quality sedation for ambulatory dental practice. This clinical trial was registered in the University Hospital Medical Information Network Clinical Trials Registry. The registration number is UMIN000039668.

Patient and staff perceptions of short procedural sedation with propofol for joint and fracture reductions in the Emergency Department: A qualitative study

BACKGROUND

Emergency Department (ED) propofol sedation is widely used to facilitate reduction of fractures and dislocations, but little is known about patient and staff perceptions of the practice. Better understanding of these aspects may improve patient care.

METHODS

A qualitative exploratory study involving semi-structured patient interviews and ED healthcare professional focus groups. Interviews with adult patients (≥16 years) >1 hour after their sedation episode were audio-recorded, anonymised and transcribed verbatim to an electronic database. Thematic analysis using a general inductive method led to development of codes and themes. ED focus groups recordings were similarly transcribed and triangulated to patient interview outcomes.

RESULTS

Data saturation was reached after 16 patient interviews. Emergent central themes from a patient perspective were: 'fear of the unknown' and 'expressed relief that the procedure was comfortable.' Key themes included 'trust in the clinical team,' 'efficacy of pain management prior to sedation' and 'quality of the information delivered to patients.' Focus group discussions around patient interview outcomes identified triage, analgesia delivery, communication, and consideration of the environment as areas for improvement.

CONCLUSIONS

ED procedural sedation with propofol is generally very well accepted by patients and clinical staff but there is scope to improve patient-focus and increase satisfaction.

Hemodynamic Influences of Remimazolam Versus Propofol During the Induction Period of General Anesthesia: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Remimazolam is a novel ultrashort-effect benzodiazepine. In 2020, the US Food and Drug Administration approved it for procedural sedation. Remimazolam is beneficial for consistent sedation and quick recovery in painless gastrointestinal endoscopy. Propofol is one of the most commonly used intravenous anesthetics in clinical practice. Recently, only a few studies have compared propofol with remimazolam for general anesthesia induction.

OBJECTIVES

The purpose of our systematic review and meta-analysis was to compare the hemodynamic effects of remimazolam and propofol during the induction of general anesthesia.

STUDY DESIGN

Systematic review and meta-analysis of randomized, controlled trials.

METHODS

The authors retrieved the PubMed, Embase, Cochrane Library, and Web of Science databases for studies published through September 30, 2022, which reported relevant prospective randomized controlled trials (RCTs) comparing remimazolam with propofol for general anesthesia. The primary outcome was hemodynamic changes, including the absolute value of fluctuation of mean arterial pressure (delta MAP) and heart rate delta HR). The secondary outcomes were the following 2 indicators: the occurrence of total adverse events and the quality of recovery from general anesthesia at 24 hours postsurgery. RevMan 5.4.1 (The Nordic Cochrane Centre for The Cochrane Collaboration) and trial sequential analysis were used to execute the statistical analyses. The different domains of bias were judged by the Cochrane risk of the bias assessment tool.

RESULTS

The authors identified 189 papers in PubMed, Embase, Cochrane Library, and Web of Science. Eight articles with 964 patients were selected. The included studies had moderate quality. For primary outcomes, the lower delta HR (mean difference [MD] = -4.99; 95% CI, -7.97 to -2.00; I² = 41.6%; P = 0.001] and delta MAP (MD = -5.91; 95% CI. -8.57 to -3.24; I² = 0%; P < 0.0001) represent more stable hemodynamic characteristics in the remimazolam group. Regarding secondary outcomes, a considerably lower incidence of total adverse events was noted in the remimazolam group than that for the propofol group (odds ratio [OR] = 0.40; 95% CI, 0.28 to 0.58; I² = 63%; P < 0.00001). In comparison to the propofol group, remimazolam achieved an advantage score of quality of recovery -15 in 24 hours postsurgery (MD = 5.31, 95% CI, 1.51 to 9.12; I² = 87%; P = 0.006).

LIMITATION

Firstly, there are only a handful of published RCTs on the administration of remimazolam in general anesthesia. In addition, due to patient privacy, we could not extract individual patient data, therefore we could not combine and assess any variations in patient characteristics.

CONCLUSION

Evidence suggests that remimazolam has a lower hemodynamic effect during general anesthesia and fewer perioperative adverse effects after general anesthesia than propofol; however, which agent is superior regarding quality benefit in postoperative recovery based on the studies included here remains inconclusive. Additional RCTs with updated meta-analyses to enlarge the sample size and properly analyze the benefit-to-risk ratio to patients are needed to determine the evidence for such a relatively new medicine.

Remimazolam Compared to Propofol for Total Intravenous Anesthesia with Remifentanil on the Recovery of Psychomotor Function: A Randomized Controlled Trial

INTRODUCTION

This study aimed to compare remimazolam to propofol in psychomotor recovery after total intravenous anesthesia (TIVA) using the Trieger dot test.

METHODS

Sixty-six patients who were scheduled to undergo endoscopic sinus surgery with American Society of Anesthesiologists (ASA) physical status I or II were randomly allocated to the remimazolam (group R) or propofol group (group P). In group R, all patients received flumazenil postoperatively. After discontinuation of anesthetic agents, the time to eye opening, response to verbal commands, extubation, and discharge from the operation room were measured. Psychomotor recovery was assessed using the Trieger dot test before induction and at 0, 30, 60, 90, 120, 150, and 180 min after anesthesia.

RESULTS

The time to eye opening, response to verbal commands, extubation, and discharge from the operation room were significantly longer in group P compared to group R (group P: 9.8 ± 3.2 min, 11.5 ± 3.4 min, 12.7 ± 3.4 min, 18.1 ± 4.2 min; group R: 6.5 ± 2 min, 7.3 ± 2.6 min, 8.4 ± 2.9 min, 13.2 ± 3.2 min; respectively, p < 0.05). In the Trieger dot test, the number of dots missed was significantly increased in group R compared to group P at 30, 60, 90, and 120 min after discharge from the operation room (group R: 20.5 ± 9.3, 16 ± 8.8, 14.9 ± 11.1, 14.3 ± 10.8; group P: 14.6 ± 7.8, 10 ± 7.1, 8.7 ± 7.3, 7.3 ± 5.7; respectively, p < 0.05). The maximum distance of dots missed was significantly increased in group R compared to group P at 30 min after discharge from the operation room (group R: 3.9 ± 2.8; group P: 2.7 ± 1.6; p < 0.05).

CONCLUSION

Our results suggest that remimazolam with flumazenil leads to rapid recovery following anesthesia; however, it may cause delayed psychomotor decline.

CLINICAL TRIAL REGISTRATION

This trial is registered with the University Hospital Medical Information Network (registration number UMIN000044900).

Requirement for Discharge in the Care of a Responsible Adult in Procedural Sedation in the Emergency Department: Necessity or Potential Barrier to Health Equity?

BACKGROUND

Procedural sedation is commonly practiced by emergency physicians to facilitate patient care in the emergency department (ED). Although various guidelines have modernized our approach to procedural sedation, many procedural sedation guidelines and practices still often require that patients be discharged into the care of a responsible adult.

DISCUSSION

Such requirement for discharge often cannot be met by underserved and undomiciled patients. Benzodiazepines, opioids, propofol, ketamine, "ketofol," etomidate, and methohexital have all been utilized for procedural sedation in the ED. For patients who may require discharge without the presence of an accompanying responsible adult, ketamine, propofol, methohexital, "ketofol," and etomidate are ideal agents for procedural sedation given rapid onsets, short durations of action, and rapid recovery times in patients without renal or hepatic impairment. Proper pre- and postprocedure protocols should be utilized when performing procedural sedation to ensure patient safety. Through the use of appropriate medications and observation protocols, patients can safely be discharged 2 to 4 h postprocedure.

CONCLUSION

There is no pharmacodynamic or pharmacokinetic basis to require discharge in the care of a responsible adult after procedural sedation. Thoughtful medication selection and the use of evidence-based pre- and postprocedure protocols in the ED can help circumvent this requirement, which likely disproportionally impacts patients who are of low socioeconomic status or undomiciled.

Lennox-Gastaut syndrome characterized by super-refractory status epilepticus treated with high-dose anesthetics: A case report

RATIONALE

Super-refractory status epilepticus is a serious illness with high morbidity and mortality, which is defined as an SE that continues or recurs 24 hours or more after the onset of anesthesia. Anesthetic agents can be either pro-convulsant or anticonvulsant or both.

PATIENT CONCERNS

Epilepsy occurred at the age of 3 years. At the age of 4 years, generalized tonic-clonic seizure occurred for the first time. The patient was hospitalized at the age of 27 and 28 years for treating status epilepticus. At the age of 33 years, antiepileptic drugs were stopped due to poor appetite. In an early morning, the patient was found delirious with reduced speech.

DIAGNOSIS

Occasionally, the patient blinked his eyelids, or deflected his eyeballs to 1 side. When propofol was lowered to 10 mL/H, the epileptic wave reduced obviously. Afterwards, the patient opened his eyes autonomously and his consciousness gradually recovered. The patient could answer questions, and the limbs had voluntary movements. The patient breathing also gradually recovered, and his urine gradually returned to pale yellow from green. After anesthetic was stopped for 10 days, the patient lost his consciousness again. The patient eyes turned upward frequently, which was relieved in 1 to 2 seconds with an attack once every 2 to 5 minutes.

INTERVENTIONS

Clonazepam was gradually reduced to 2 mg qn, and the patient gradually woke up during this process. The patient was also treated with levetiracetam 1.5 g bid, oxcarbazepine 0.6 g bid, topiramate 50 mg bid and valproate 0.4 g tid.

OUTCOMES

After 1 month follow-up, status epilepticus did not appear again.

LESSONS

Propofol aggravated the tonic seizures. As tonic seizures occur during natural sleep and after sleep induced by various narcotic drugs, the decrease of consciousness level induced by excessive sedation of narcotic drugs has been suggested as the reason for poor seizure control.

Successful management of suspected propofol dependence with phenobarbital in an adult patient with COVID-19

PURPOSE

In critically ill patients, high sedation requirements for prolonged durations are often needed to achieve ventilator synchrony, a practice that was particularly common during the early stages of the coronavirus disease 2019 (COVID-19) pandemic. We report the successful use of phenobarbital to facilitate propofol weaning after prolonged medication exposure.

SUMMARY

A 64-year-old male with hypertension was admitted for the management of acute respiratory distress syndrome due to COVID-19 pneumonia. The patient received high doses of fentanyl and propofol with periods of concomitant midazolam and dexmedetomidine throughout his prolonged time on mechanical ventilation. Total days of exposure were 19 for fentanyl, 17 for propofol, 12 for midazolam, and 15 for dexmedetomidine. Upon improvement in lung function, attempts to wean the patient from propofol all failed due to symptoms such as tachypnea, tachycardia, and hypertension, with symptom resolution only upon return to the previous dose. Phenobarbital was trialed for possible propofol withdrawal syndrome, allowing for a dose reduction of 10 μg/kg/min within 2 hours of the first dose without any corresponding symptoms. The patient continued to receive intermittent doses of phenobarbital for another 36 hours until propofol was discontinued. He underwent tracheostomy shortly after weaning off all sedation and was discharged to rehab 34 days after his initial admission.

CONCLUSION

Information concerning propofol withdrawal syndrome in the literature is limited. Our experience demonstrates the successful use of phenobarbital to facilitate propofol weaning after prolonged exposure.

Propofol suppresses OGD/R-induced ferroptosis in neurons by inhibiting the HIF-1α/YTHDF1/BECN1 axis

BACKGROUND

Ischemia/reperfusion (I/R) is a pathological process that causes severe damage. Propofol is known to alleviate I/R-related injury; however, the exact function and underlying mechanisms are not fully understood.

METHODS

Using an oxygen glucose deprivation/re-oxygenation (OGD/R) method, an in vitro I/R injury model was induced. The cell viability and the level of Fe2+, glutathione synthetase (GSH), and malondialdehyde (MDA) were evaluated using kits. Luciferase reporter gene assay, chromatin immunoprecipitation, and RNA immunoprecipitation (RIP) were used to verify the interaction between molecules. The m6A level of BECN1 mRNA was determined through methylated RIP.

RESULTS

Propofol-treated OGD/R models showed reduced levels of Fe2+ and MDA, while the cell viability and the level of GSH increased. Propofol inhibited ferroptosis by down-regulating HIF-1α in OGD/R-treated HT22 cells. HIF-1α is bound to the promoter region of YTHDF1 to promote its transcription, and YTHDF1 promoted ferroptosis by stabilizing the mRNA of BECN1. The suppressive effect of propofol on OGD/R-induced ferroptosis was reversed by the overexpression of YTHDF1.

CONCLUSIONS

Our study revealed that the HIF-1α/YTHDF1/BECN1 axis in OGD/R-treated HT22 cells promotes ferroptosis, and administration of propofol can inhibit this axis to avoid cell death. This study provides a novel insight for the neuroprotective function of propofol.

Clinical and genetic factors associated with post-operative nausea and vomiting after propofol anaesthesia

BACKGROUND

The incidence of post-operative nausea and vomiting (PONV) remains at about 30% despite all therapeutic efforts to reduce it. The clinical risk factors guiding the prophylactic treatment are well established, but genetic factors associated with PONV remain poorly known. The aim of this study was to explore clinical and genetic factors impacting PONV by performing a genome-wide association study (GWAS) together with relevant clinical factors as covariates, and systematically attempt to replicate previously reported PONV associations. Relevant clinical factors are explored with logistic regression model.

METHODS

This was an observational case control study in Helsinki University Hospital between 1 August 2006 and 31 December 2010. One thousand consenting women with elevated risk for PONV, undergoing breast cancer surgery with standardised propofol anaesthesia and antiemetics. After exclusions for clinical reasons and failed genotyping, 815 patients were included with 187 PONV cases and 628 controls. Emergence of PONV up to 7th post-operative day was recorded. PONV at 2-24 h after surgery was selected to be the primary outcome. The GWAS explored associations between PONV and 653 034 genetic variants. Replication attempts included 31 variants in 16 genes.

RESULTS

The overall incidence of PONV up to 7th post-operative day was 35%, where 3% had PONV at 0-2 h and 23% at 2-24 h after surgery. Age, American Society of Anaesthesiologists status, the amount of oxycodone used in the post-anaesthesia care unit, smoking status, previous PONV, and history of motion sickness were statistically significant predictive factors in the logistic model. The receiver operating characteristic-area under the curve of 0.75 (95% CI 0.71-0.79) was calculated for the model. The GWAS identified six variants with suggestive association to PONV (p < 1 × 10-5 ). Of the previously reported variants, association with the DRD2 variant rs18004972 (TaqIA) was replicated (p = .028).

CONCLUSIONS

Our GWAS approach did not identify any high-impact PONV susceptibility variants. The results provide some support for a role of dopamine D2 receptors in PONV.

Effect of sevoflurane on CD4+CD25+FOXP3+ regulatory T cells in patients with gastric cancer undergoing radical surgery

In this study, the proportion of CD4+CD25+FOXP3+ regulatory T (Treg) cells in CD4+ T cells in the peripheral blood of gastric cancer patients before anesthesia induction (T1), after surgery (T2) and the first day after surgery (T3) was studied to explore the effect of sevoflurane and propofol anesthesia on the prognosis of gastric cancer patients. Forty patients with advanced gastric cancer were recruited and randomly divided into the sevoflurane group (S group) and the propofol group (T group). Flow cytometry was used to detect the proportion of CD4+CD25+FOXP3+ Treg cells in CD4+ T cells in the peripheral blood of patients with T1, T2 and T3, respectively. Compared with stage ⅡB, the proportion of CD4+CD25+FOXP3+ Treg cells in T1, T2 and T3 of stage ⅢA and stage ⅢB patients was increased. Compared with the T group, the expression of CD4+CD25+FOXP3+ Treg cells in the peripheral blood of T2 and T3 in the S group was decreased. The results showed that the expression of CD4+CD25+FOXP3+ Treg cells might be related to the TNM stage of gastric cancer and sevoflurane could alleviate the inhibition of postoperative immune function more than propofol. Sevoflurane effectively reduced the expression level of CD4+CD25+FOXP3+ Treg cells in peripheral blood of T2 and T3 of patients with gastric cancer, providing the theoretical basis for the selection of surgical anesthetics for patients with gastric cancer.

Dexmedetomidine vs. propofol sedation reduces the duration of mechanical ventilation after cardiac surgery - a randomized controlled trial

OBJECTIVE

The aim of our study was to compare the clinical effects of sedation with dexmedetomidine vs. propofol in patients undergoing cardiac surgery and analyze their effects on the duration of mechanical ventilation (MV), length of stay in the intensive care unit (ICU), and total hospital stay.

PATIENTS AND METHODS

The study included 120 patients who were randomized in a 1:1 ratio into two groups of 60 patients. The first group was sedated with continuous dexmedetomidine in doses 0.2-0.7 mcg/kg/h. The second group was sedated with propofol in doses 1-2 mg/kg/h.

RESULTS

Patients sedated with dexmedetomidine required 2.2 hours less time on MV (p<0.001). There was a positive correlation between the duration of MV and the ICU length of stay (r=0.368; p<0.001), as well as between the duration of MV and the total hospital stay (r=0.204; p=0.025). Delirium occurred in the postoperative period in 25% of patients sedated with propofol, while in the dexmedetomidine group it was only 11.7% (p=0.059). Patients who developed delirium had a significantly longer duration of MV (12.6±5.4 vs. 9.3±2.5 hours, p=0.010).

CONCLUSIONS

Postoperative sedation with dexmedetomidine, compared to propofol, reduces the duration of MV, but does not influence the length of stay in the ICU and length of hospitalization after open heart surgery.

Targeting Slow Wave Sleep Deficiency in Late-Life Depression: A Case Series With Propofol

Slow wave sleep (SWS), characterized by large electroencephalographic oscillations, facilitates crucial physiologic processes that maintain synaptic plasticity and overall brain health. Deficiency in older adults is associated with depression and cognitive dysfunction, such that enhancing sleep slow waves has emerged as a promising target for novel therapies. Enhancement of SWS has been noted after infusions of propofol, a commonly used anesthetic that induces electroencephalographic patterns resembling non-rapid eye movement sleep. This paper 1) reviews the scientific premise underlying the hypothesis that sleep slow waves are a novel therapeutic target for improving cognitive and psychiatric outcomes in older adults, and 2) presents a case series of two patients with late-life depression who each received two propofol infusions. One participant, a 71-year-old woman, had a mean of 2.8 minutes of evening SWS prior to infusions (0.7% of total sleep time). SWS increased on the night after each infusion, to 12.5 minutes (5.3% of total sleep time) and 24 minutes (10.6% of total sleep time), respectively. Her depression symptoms improved, reflected by a reduction in her Montgomery-Asberg Depression Rating Scale (MADRS) score from 26 to 7. In contrast, the other participant, a 77-year-old man, exhibited no SWS at baseline and only modest enhancement after the second infusion (3 minutes, 1.3% of total sleep time). His MADRS score increased from 13 to 19, indicating a lack of improvement in his depression. These cases provide proof-of-concept that propofol can enhance SWS and improve depression for some individuals, motivating an ongoing clinical trial (ClinicalTrials.gov NCT04680910).

The differential cancer growth associated with anaesthetics in a cancer xenograft model of mice: mechanisms and implications of postoperative cancer recurrence

Anaesthetics may modify colorectal cancer cell biology which potentially affects long-term survival. This study aims to compare propofol and sevoflurane regarding with the direct anaesthetic effects on cancer malignancy and the indirect effects on host immunity in a cancer xenograft mode of mice. Cultured colon cancer cell (Caco-2) was injected subcutaneously to nude mice (day 1). Mice were exposed to either 1.5% sevoflurane for 1.5 h or propofol (20 μg g-1; ip injection) with or without 4 μg g-1 lipopolysaccharide (LPS; ip) from days 15 to 17, compared with those without anaesthetic exposure as controls. The clinical endpoints including tumour volumes over 70 mm3 were closely monitored up to day 28. Tumour samples from the other cohorts were collected on day 18 for PCR array, qRT-PCR, western blotting and immunofluorescent assessment. Propofol treatment reduced tumour size (mean ± SD; 23.0 ± 6.2mm3) when compared to sevoflurane (36.0 ± 0.3mm3) (p = 0.008) or control (23.6 ± 4.7mm3). Propofol decreased hypoxia inducible factor 1α (HIF1α), interleukin 1β (IL1β), and hepatocyte growth factor (HGF) gene expressions and increased tissue inhibitor of metalloproteinases 2 (TIMP-2) gene and protein expression in comparison to sevoflurane in the tumour tissue. LPS suppressed tumour growth in any conditions whilst increased TIMP-2 and anti-cancer neutrophil marker expressions and decreased macrophage marker expressions compared to those in the LPS-untreated groups. Our data indicated that sevoflurane increased cancer development when compared with propofol in vivo under non-surgical condition. Anaesthetics tested in this study did not alter the effects of LPS as an immune modulator in changing immunocyte phenotype and suppressing cancer development.

The effect of playing music and mother's voice to children on sedation level and requirement during pediatric magnetic resonance imaging

BACKGROUND

Magnetic resonance imaging examinations frequently cause anxiety and fear in children. The objective of this study was to investigate the effects of listening to music sound, the mother's voice, and sound isolation on the depth of sedation and need for sedatives in pediatric patients who would undergo MRI.

METHODS

Ninety pediatric patients aged 3 to 12 years who were planned for imaging in the MRI unit were randomly assigned to isolation group (Group I), musical sound group (Group II), and mother's voice group (Group III). We evaluated patients' anxiety and sedation levels via the Observer's Assessment of Alertness/Sedation (OAA/S) RESULTS: Heart rate, oxygen saturation, OAA/S, and Ramsey scores during the procedure were not significantly different among the groups (p>0.05). The mean amount of propofol and total propofol consumption was statistically lower in the mother's voice group than in the isolation and music sound groups (p<0.001). Mean propofol amount and total propofol consumption were not significantly different in isolation and music sound groups (p>0.05). No difference was found between the groups regarding the time it took for the patients' Modified Aldrete score to reach 9 (p>0.05).

CONCLUSIONS

In pediatric patients, listening to the mother's voice during MRI decreased the total sedative requirement consumed without increasing the depth of sedation.

Effectiveness of remimazolam besylate combined with alfentanil for fiberoptic bronchoscopy with preserved spontaneous breathing: a prospective, randomized, controlled clinical trial

OBJECTIVE

The novel short-acting benzodiazepine remimazolam besylate acts rapidly and is used to induce easily controlled sedation. The aim of this study was to investigate the effects of remimazolam besylate combined with alfentanil in patients undergoing fiberoptic bronchoscopy with preserved spontaneous breathing.

PATIENTS AND METHODS

192 patients undergoing painless fiberoptic bronchoscopy were randomly assigned to either propofol (P group) or remimazolam besylate (R group); both groups also received alfentanil 10 µg/kg. The respiratory rate was recorded during the inspection. Mean arterial pressure (MAP), heart rate (HR), oxygen saturation (SpO2), Narcotrend values and Modified Observer's Assessment of Alertness and Sedation (MOAA/S) scores were recorded after entry to the operating room (T0), 1 min (T1), 2 min (T2) and 3 min (T3) after anesthesia, immediately after the bronchoscope entered the vocal cords (T4), when the bronchoscope reached the carina (T5), the patient's eyes opened (T6), and 30 min postoperatively (T7). Secondary outcomes included intraoperative hypotension and body movement grading, etc. RESULTS: There was less respiratory depression during the inspection in the R group than in the P group (p < 0.01). The rate of hypotension during the examination was higher in the P group than in the R group (p < 0.01). Narcotrend values in the P group were less for the R group at the T1-T5 time points (p < 0.01). No difference in the number of body movements ≥ grade 3 was found between the two groups (p > 0.05).

CONCLUSIONS

Remimazolam besylate combined with alfentanil for painless fiberoptic bronchoscopy can better preserve the patient's spontaneous breathing and reduce the incidence of respiratory depression during the inspection than propofol.

Optimization of procedural sedation and analgesia during atrial fibrillation ablation

PURPOSE OF REVIEW

This mini-review is aimed to provide an overview and discuss procedural sedation and analgesia for atrial fibrillation (AF) ablation with focus at qualification of staff, patient evaluation, monitoring, medication and postprocedural care.

RECENT FINDINGS

Sleep-disordered breathing is highly prevalent in patients with AF. Impact of often used STOP-BANG questionnaire to detect sleep-disordered breathing in AF patients is limited due to its restricted validity. Dexmedetomidine is a commonly used drug in sedation, but is shown not to be superior to propofol in sedation during AF-ablation. Alternatively use of remimazolam has characteristics that makes it a promising drug for minimal to moderate sedation for AF-ablation. High flow nasal oxygen (HFNO) has shown to reduce the risk of desaturation in adults receiving procedural sedation and analgesia.

SUMMARY

An optimal sedation strategy during AF ablation should be based on AF patient characteristics, the level of sedation needed, the procedure (duration and type of ablation) and the education and experience of the sedation provider. Patient evaluation and post procedural care are part of sedation care. More personalized care based on use of various sedation strategies and types of drugs as related to the type of AF-ablation is the way to further optimize care.

Evaluation of clinical effects of Esketamine on depression in patients with missed miscarriage: A randomized, controlled, double-blind trial

BACKGROUND

Patients with missed miscarriages are usually accompanied by varying degrees of depression, which is closely related to the patient's prognosis. We investigated whether Esketamine could alleviate postoperative depression symptoms in patients with missed miscarriages who underwent painless curettage.

METHODS

This study was a randomized, parallel-controlled, double-blind, single-center trial. A total of 105 patients with preoperative 1d (EPDS) ≥ 10 were randomly assigned to the Propofol; Dezocine; Esketamine group. Patients record EPDS at 7 and 42 days after the operation. Secondary outcomes included VAS for 1 h postoperation, total propofol usage, adverse reactions, And the expressions of inflammatory factors of TNF-α, IL-1β, IL-6, IL-8, and IL-10.

RESULTS

Compared with the P and D group, patients in the S group had lower EPDS scores at 7 day (8.63 ± 3.14, 9.17 ± 3.23 vs. 6.34 ± 2.87 P = 0.0005) and 42 days (9.40 ± 2.67, 8.49 ± 3.05 vs.5.31 ± 2.49 P < 0.0001) after the operation. Respectively, Compared with the P group, the VAS scores (3.51 ± 1.12 vs. 2.80 ± 0.83, 2.40 ± 0.81, P = 0.0035) and the dosage of propofol used during operation (198.7 ± 47.48 vs. 145.5 ± 19.31, 142.9 ± 21.01 P < 0.0001) were lower in the D and S groups, and lower postoperative inflammatory response at 1 day after surgery. Other outcomes among the three groups were not found to the difference.

CONCLUSIONS

Esketamine effectively treated postoperative depressive symptoms of patients with a missed miscarriage, decreasing propofol consumption and inflammatory response.

Popliteal sciatic nerve block for high-risk patients undergoing lower limb angioplasty: A prospective double-blinded randomized controlled trial

BACKGROUND

To assess the rate of conversion to general anesthesia, sedative and analgesic drug-sparing effects, and complications of popliteal sciatic nerve block (PSNB) compared with a sham block during lower limb angioplasty.

METHODS

A randomized, controlled, double-blinded trial of patients with chronic limb-threatening ischemia (CLTI) who receive PSNB with 0.25% levobupivacaine 20 mL compared with a sham block (control) during lower limb angioplasty. Pain scores, conversion rate to general anesthesia, amount of sedoanalgesia drug usage, complications, and satisfaction with the anesthesia technique by surgeons and patients were assessed.

RESULTS

Forty patients were enrolled in this study. Two of 20 (10%) control group patients were converted to general anesthesia, while none of the patients in the intervention group required general anesthesia (P = .487). Pain scores before PSNB did not differ between the groups (P = .771). After the block, pain scores in the block group were lower than those in the control group: 0 (0, 1.5) (median, interquartile range) and 2.5 (0.5, 3.5), respectively (P = .024). The analgesic effect persisted until immediately after the surgery (P = .035). There was no difference in pain scores at the 24-hours follow-up visit (P = .270). The total propofol and fentanyl dosage requirements, a number of patients who required propofol and fentanyl, side effects, and satisfaction were not different between the groups. No major complications were noted.

CONCLUSIONS

PSNB provided effective pain relief during and immediately after lower limb angioplasty, but did not statistically affect the rate of conversion to general anesthesia, sedoanalgesia drug usage, or complications.

Propofol Inhibits Ferroptotic Cell Death Through the Nrf2/Gpx4 Signaling Pathway in the Mouse Model of Cerebral Ischemia-Reperfusion Injury

Ferroptosis is characterized by excessive accumulation of iron and lipid peroxides, which are involved in ischemia, reperfusion-induced organ injury, and stroke. Propofol, an anesthetic agent, has neuroprotective effects due to its potent antioxidant, anti-ischemic, and anti-inflammatory properties. However, the relationship between propofol and ferroptosis is still unclear. In the current study, we elucidated the role of ferroptosis in the neuroprotective effect of propofol in mouse brains subjected to cerebral ischemia reperfusion injury (CIRI). Ferroptosis was confirmed by Western blotting assays, transmission electron microscopy, and glutathione assays. Propofol regulated Nrf2/Gpx4 signaling, enhanced antioxidant potential, inhibited the accumulation of lipid peroxides in CIRI-affected neurons, and significantly reversed CIRI-induced ferroptosis. Additionally, Gpx4 inhibitor RSL3 and Nrf2 inhibitor ML385 attenuated the effects of propofol on antioxidant capacity, lipid peroxidation, and ferroptosis in CIRI-affected neurons. Our data support a protective role of propofol against ferroptosis as a cause of cell death in mice with CIRI. Propofol protected against CIRI-induced ferroptosis partly by regulating the Nrf2/Gpx4 signaling pathway. These findings may contribute to the development of future therapies targeting ferroptosis induced by CIRI.

Propofol misuse in medical professions: a scoping review

PURPOSE

We aimed to describe the current literature concerning propofol misuse in medical professionals, specifically relating to the individual demographics of those misusing propofol and the outcomes of propofol misuse.

METHODS

We conducted a retrospective scoping review of the literature using a modified PRISMA approach. We used MEDLINE, EMBASE, and PsycINFO databases to identify relevant studies based on search terms. Studies describing individual medical professionals misusing propofol were included.

RESULTS

Twenty-four articles describing 88 individual cases of propofol misuse were included for data charting and analysis. Anesthesiologists and certified registered nurse anesthetists were most commonly identified. Death was a common method of identification of misuse, while rehabilitation and death were common final outcomes associated with propofol misuse.

CONCLUSIONS

Despite knowledge of the pharmacokinetic and pharmacodynamic properties of propofol by those misusing this medication, death was a common outcome reported in the literature. Data related to long-term outcomes including re-entry to clinical practice or success of rehabilitation were limited.